Gnatostomiasis cutánea, primer caso confirmado en Colombia / Cutaneous gnathostomiasis, first confirmed case in Colombia

La gnatostomiasis es una zoonosis parasitaria causada por algunas especies del género de helmintos Gnathostoma . La presentación clínica es muy variada y su diagnóstico constituye un desafío; es endémica en países tropicales y subtropicales, y la transmisión se asocia con el consumo de carne de animales acuáticos, cruda o mal cocida. En las últimas décadas, el creciente turismo internacional y el consumo de alimentos exóticos, han provocado un notable aumento de casos de la enfermedad. En nuestro país no se ha reportado ningún caso confirmado de gnatostomiasis. Se presenta el caso de un hombre colombiano de 63 años de edad, viajero frecuente al exterior, que consultó por presentar síntomas gastrointestinales. Durante la hospitalización desarrolló una lesión cutánea en el flanco abdominal derecho, de la cual se extrajo una larva cuya descripción morfológica permitió clasificarla como Gnathostoma spinigerum . Se trata de la primera confirmación de un caso importado de gnatostomiasis en Colombia. En este artículo se discuten las generalidades, la etiología, la patogenia y el tratamiento de la enfermedad, con especial énfasis en las características particulares de este paciente.

Gnathostomiasis is a parasitic zoonosis caused by some species of helminthes belonging to the genus Gnathostoma . It has a wide clinical presentation and its diagnosis is a challenge. Tropical and subtropical countries are endemic, and its transmission is associated with eating raw or undercooked meat from fresh water animals. Increasing global tourism and consuming exotic foods have produced a noticeable rise in cases of the disease in the last decades. However, in our country, there has not been any confirmed case of gnathostomiasis previously reported. We present the case of a 63-year-old Colombian man with an international travel history, who presented with gastrointestinal symptoms. During the hospital stay, he developed a cutaneous lesion on the upper right abdominal quadrant, where later, a larva was found. A morphological study allowed us to identify it as Gnathostoma spinigerum . As such, this is the first report of an imported case of gnathostomiasis confirmed in Colombia. This article describes the principles, etiology, pathogenic cycle and treatment of this disease with special considerations to our patient´s particular features.

Imported Intraocular Gnathostomiasis with Subretinal Tracks Confirmed by Western Blot Assay

We report a case of intraocular gnathostomiasis diagnosed by western blot assay in a patient with subretinal tracks. A 15-year-old male patient complained of blurred vision in the right eye, lasting for 2 weeks. Eight months earlier, he had traveled to Vietnam for 1 week and ate raw wild boar meat and lobster. His best-corrected visual acuity was 20/20 in both eyes and anterior chamber examination revealed no abnormalities. Fundus examination showed subretinal tracks in the right eye. Fluorescein angiography and indocyanine green angiography showed linear hyperfluorescence of the subretinal lesion observed on fundus in the right eye. Ultrasound examination revealed no abnormalities. Blood tests indicated mild eosinophilia (7.5%), and there was no abnormality found by systemic examinations. Two years later, the patient visited our department again for ophthalmologic evaluation. Visual acuity remained 20/20 in both eyes and the subretinal tracks in the right eye had not changed since the previous examination. Serologic examination was performed to provide a more accurate diagnosis, and the patient's serum reacted strongly to the Gnathostoma nipponicum antigen by western blot assay, which led to a diagnosis of intraocular gnathostomiasis. This is the first reported case of intraocular gnathostomiasis with subretinal tracks confirmed serologically using western blot in Korea.

Positivity and Intensity of Gnathostoma spinigerum Infective Larvae in Farmed and Wild-Caught Swamp Eels in Thailand

From July 2008 to June 2009, livers of the swamp eels (Monopterus alba) were investigated for advanced third-stage larvae (AL3) of Gnathostoma spinigerum. Results revealed that 10.2% (106/1,037) and 20.4% (78/383) of farmed eels from Aranyaprathet District, Sa Kaeo Province and those of wild-caught eels obtained from a market in Min Buri District of Bangkok, Thailand were infected, respectively. The prevalence was high during the rainy and winter seasons. The infection rate abruptly decreased in the beginning of summer. The highest infection rate (13.7%) was observed in September and absence of infection (0%) in March-April in the farmed eels. Whereas, in the wild-caught eels, the highest rate (30.7%) was observed in November, and the rate decreased to the lowest at 6.3% in March. The average no. (mean+/-SE) of AL3 per investigated liver in farmed eels (1.1+/-0.2) was significantly lower (P=0.040) than those in the caught eels (0.2+/-0.03). In addition, the intensity of AL3 recovered from each infected liver varied from 1 to 18 (2.3+/-0.3) in the farmed eels and from 1 to 47 (6.3+/-1.2) in the caught eels, respectively. The AL3 intensity showed significant difference (P=0.011) between these 2 different sources of eels. This is the first observation that farmed eels showed positive findings of G. spinigerum infective larvae. This may affect the standard farming of the culture farm and also present a risk of consuming undercooked eels from the wild-caught and farmed eels.

Discovery of Larval Gnathostoma nipponicum in Frogs and Snakes from Jeju-do (Province), Republic of Korea

A survey was performed to find out the intermediate hosts of Gnathostoma nipponicum in Jeju-do (Province), the Republic of Korea. In August 2009 and 2010, a total of 82 tadpoles, 23 black-spotted pond frogs (Rana nigromaculata), 7 tiger keelback snakes (Rhabdophis tigrinus tigrinus), 6 red-tongue viper snakes (Agkistrodon ussuriensis), and 2 cat snakes (Elaphe dione) were collected in Jeju-do and examined by the pepsin-HCl digestion method. Total 5 gnathostome larvae were detected in 3 (50%) of 6 A. ussuriensis, 70 larvae in 3 of 7 (42.9%) R. tigrinus tigrinus, and 2 larvae in 2 of 82 (8.7%) frogs. No gnathostome larvae were detected in tadpoles and cat snakes. The larvae detected were a single species, and 2.17x0.22 mm in average size. They had characteristic head bulbs, muscular esophagus, and 4 cervical sacs. Three rows of hooklets were arranged in the head bulbs, and the number of hooklets in each row was 29, 33, and 36 posteriorly. All these characters were consistent with the advanced third-stage larvae of G. nipponicum. It has been first confirmed in Jeju-do that R. nigromaculata, A. ussuriensis, and R. tigrinus tigrinus play a role for intermediate and/or paratenic hosts for G. nipponicum.

Gnathostoma hispidum Infection in a Korean Man Returning from China

Human Gnathostoma hispidum infection is extremely rare in the world literature and has never been reported in the Republic of Korea. A 74-year-old Korean man who returned from China complained of an erythematous papule on his back and admitted to our hospital. Surgical extraction of the lesion and histopathological examination revealed sections of a nematode larva in the deep dermis. The sectioned larva had 1 nucleus in each intestinal cell and was identified as G. hispidum. The patient recalled having eaten freshwater fish when he lived in China. We designated our patient as an imported G. hispidum case from China.

Spinal gnathostomiasis resembling an intrinsic cord tumor/myelitis in a 4-year-old boy.

A 4-year-old boy presented with fever, myalgia followed by progressive quadriparesis and urinary retention. Spinal fluid from a lumbar puncture showed 42 WBC/microl with 100% lymphocytes, no RBC, a glucose of 54 mg/dl (blood glucose 107 mg/dl), and a protein of 39 mg/dl. The cerebrospinal fluid culture was negative. His white blood cell count was 10,860 cells/microl with a normal differential count. An MRI of the brain was negative. An MRI of the whole spine showed fusiform dilatation of the cervical cord from the cervicomedullary junction to the T4 level. The tentative diagnosis was acute hemorrhage of an intrinsic cord tumor versus acute myelitis. Intravenous dexamethasone was administered which resulted in a slight improvement in strength. One week later, he deteriorated precipitously and became flaccidly quadriplegic. Since the patient deteriorated rapidly and no definitive diagnosis was made, the patient underwent cervical cord biopsy. Intraoperatively, after the cervical cord had been opened, a living Gnathostoma spinigerum was found in the spinal cord parenchyma. The nematode was removed. Following the operation the patient was placed on albendazole 400 mg/d and metronidazole 250 mg three times per day for 3 weeks. He gradually improved over the next several weeks.

Hypereosinophilia and abdominopulmonary gnathostomiasis.

A 16-year-old Thai male presented with sudden onset severe epigastric and right upper quadrant pain, fever (39 degrees C), chills and malaise. He gave no history of underlying disease, migratory swelling or urticarial skin rash. He had a history of frequently eating raw pork. Physical examination revealed a soft abdomen with markedly tender hepatomegaly. His blood count showed extreme leukocytosis with hypereosinophilia. After admission he developed a non-productive cough with left sided chest pain, a chest x-ray showed a left pleural effusion. Serological findings were positive for Gnathostoma larval antigen but not Fasciola antigen. The patient recovered completely after albendazole treatment. His clinical presentation is compatible with abdominopulmonary hypereosinophilic syndrome or visceral larva gnathostomiasis. The presented case is interesting not only for physicians who work in endemic areas of gnathostomiasis but also for clinicians who work in travel medicine clinics in developed countries, to consider abdominopulmonary gnathostomiasis when patients present with the signs and symptoms of visceral larva migrans.

Detection of Gnathostoma spinigerum Third-Stage Larvae in Snakeheads Purchased from a Central Part of Myanmar

To examine the infection status of freshwater fish with Gnathostoma spp. larvae in Myanmar, we purchased 15 snakeheads, Channa striatus, from a local market in a suburban area of Naypyidaw, the new capital city. Two larval gnathostomes were collected using an artificial digestion technique, and observed by a light microscope and a scanning electron microscope. The size of an intact larva was 2.65 mm long and 0.32 mm wide. The characteristic morphology of the larvae included the presence of a long esophagus (0.80 mm long), 2 pairs of cervical sacs (0.43 mm long), and a characteristic head bulb with 4 rows of hooklets. The number of hooklets in the 1st, 2nd, 3rd, and 4th row was 45, 48, 50, and 52, respectively. Based on these morphological characters, the larvae were identified as the advanced 3rd-stage larvae of Gnathostoma spinigerum. This is the first report of detection of G. spinigerum 3rd-stage larvae in the central part of Myanmar. Our study suggests that intake of raw meat of snakehead fish in Myanmar may result in human gnathostomiasis.

Gnathostomiasis of the anterior chamber.

Ocular involvement with Gnathostoma spinigerum occurs years after the initial infection that is acquired by ingestion of poorly cooked, pickled seafood or water contaminated with third stage larvae. Here we report a case of gnathostomiasis of the left eye of a 32-year-old lady hailing from Meghalaya, India. Her vision had deteriorated to hand movement. Slit lamp examination revealed a live, actively motile worm in the anterior chamber, which was extracted by supra temporal limbal incision and visual acuity was restored.

Larval Gnathostoma hispidum detected in the red banded odd-tooth snake, Dinodon rufozonatum rufozonatum, from China

A total of 205 larval gnathostomes were collected from 18 (22.5%) of 80 red banded odd-tooth snakes, Dinodon rufozonatum rufozonatum, which had been smuggled from China and confiscated at Customs in Busan, Republic of Korea. In order to identify the species, some of the larvae were observed by a light microscope and a scanning electron microscope (SEM). The larvae were 2.18 x 0.29 mm in average size, and had a pair of lips at the anterior end, a muscular esophagus, 2 pairs of cervical sacs, and brownish intestines. The head bulb was characteristically equipped with 4 rows of hooklets; the average number of hooklets in each respective row was 38.6, 40.5, 41.5, and 43.7. In SEM views, the mouth evidenced a pair of lateral lips of equal size in a half-moon shape. Each lip featured a couple of labial papillae and a small amphid located between the 2 papillae. The hooklets on the head bulb had single-pointed, posteriorly-curved tips. The cuticular spines were larger and more densely distributed on the anterior part of the body, and decreased gradually in size and number toward the posterior body. On the basis of these morphological characteristics, the larvae were identified as the third stage larvae of Gnathostoma hispidum.

Feasibility of using papaya skin extract for digestion of swamp eel viscera for harvesting infective stage larva of Gnathostoma spp.

In this study, we reported the feasibility of using papaya skin extract (Carica papaya L.) as an alternative to enzyme pepsin in harvesting Gnathostoma spinigerum third-stage larvae. From experimental digestion, we found that the different numbers of recovered larvae between papaya skin extract and pepsin were not statistically significant (p >0.05). When the derived larvae from pepsin and papaya skin extract digestion were cultivated in BME medium for 7 days, the survival rates were not significantly different either (p >0.05). Thus, papaya skin extract might be another choice for recovering Gnathostoma spinigerum third-stage larvae.

Gnathostoma infection in fish caught for local consumption in Nakhon Nayok Province, Thailand. II. Deasonal variation in swamp eels.

From August 2000 to August 2001, 1844 swamp eels (Monopterus albus) were purchased from several local markets in Nakhon Nayok Province, Thailand, and examined for the presence of Gnathostoma advanced third-stage larvae. The overall prevalence was 30.1% and the mean number of larvae/eel (infection intensity) was 10.0. The highest infection rate (44.1%) was found in August 2000 and the lowest (10.7%) in March 2001. The greatest mean number of larvae/eel (75.1) was found in August 2000, whereas the fewest (2.3) was in July 2001. It is suggested that the prevalence and intensity of infection decreased within two months after the end of the rainy season and started to rise again about two months after the next rainy season began. A total of 5,532 Gnathostoma larvae were recovered from 555 infected eels, with a maximum number of 698 larvae/eel. The highest rates of Gnathostoma infection according to eel body length and weight were 87.5% in the group 91-100 cm, and 100% in groups of 901-1100 g, respectively. There were significant correlations between eel body lengths and infection rates, body lengths and infection intensities; eel body weights were also significantly correlated with infection rates and infection intensities. It was noted that the longer/ heavier the eels were, the higher would be the infection rates and the greater the infection intensities. Tissue distributions of Gnathostoma larvae in the livers and muscles of swamp eels were as follows: 43.0% of the total number of larvae were found in the muscles and 57.0% were in the liver; 29.7, 51.7, and 18.6% were in the anterior, middle, and posterior parts, respectively; 35.1% were in the dorsal part, while 64.9% were in the ventral part; 9.0, 18.7, 7.4, 20.6, 33.1, and 11.2% were in the anterodorsal, mediodorsal, posterodorsal, anteroventral, medioventral and posteroventral parts, respectively. Of the 5,532 Gnathostoma larvae examined, 1101 (19.9%) were found to possess morphological variants or abnormal cephalic hooklets. The most common unusual feature was that there were few to numerous extra rudimentary hooklets below row 4 and between the 4 rows of hooklets (7.6%), the presence of a fifth row of hooklets (3.5%), abnormal hooklets in any of the 4 rows of hooklets (5.2%), spiral arrangement of the 4 rows of hooklets (1.8%), and larvae having only 3 rows of hooklets (0.3%).

Gnathostoma binucleatum (Spirurida: Gnathostomatidae) en peces dulceacuícolas de Tabasco, México / Gnathostoma binucleatum (Spirurida: Gnathostomatidae) from the freshwater fish in Tabasco, Mexico

Human gnathostomiasis is a food-born parasitic disease of relative importance in many countries in Southeast Asia. It is caused by several species of nematodes of the genus Gnathostoma. In Mexico is an emerging public health problem since 1970, when first cases were reported. Until today, larval morphometric characters that have been proposed to differentiate between the three species of Gnathostoma present in this country, are not satisfactory. Recently, the presence of advanced third-stage larvae AdvL3 (infective form for humans) in freshwater fishes from Pantanos de Centla, Tabasco. was recorded but their specific identity was not clarified . Examination of four species of freshwater fishes from the same locality revealed that three of them: Petenia splendida (n=58), Cichlasoma managuense (n=35) and Gobiomorus dormitor (n=9) were infected by 15 AdvL3 of Gnathostoma binucleatum. Specific identity was obtained comparing the internal transcribed spacer 2 (ITS2) of the ribosomal DNA with sequences reported in Genbank. This is the first record of G. binucleatum in P. splendida and G. dormitor from Tabasco and the first specific determination of the parasite in the locality.

Intravitreal live Gnathostoma spinigerum.

Intraocular infestation by live Gnathostoma spinigerum is a rare occurrence in humans. Most of the published reports are from South-East Asia. We report a case of intravitreal gnathostomiasis, where the worm was removed live and intact by pars plana vitrectomy.

Case report: intraocular gnathostomiasis in Vietnam.

This is the report of the first case of intraocular gnathostomiasis diagnosed in Vietnam. The disease progressed in two months in two distinct phases: in the first phase, the patient had swellings, which appeared at different times and in different locations, on his face--this phase lasted around one month; the second phase was the embedding of the parasite in the vitreous cavity of the right eye and uveitis. Surgical extraction of a living Gnathostoma larva was carried out. Based on morphological, histological criteria, the larva may have been an atypical third-stage of Gnathostoma spinigerum.

Intraocular gnathostomiasis.

We report a rare case of intraocular Gnathostomiasis, where a live worm, intracameral in location, was successfully removed. Its identity was confirmed by microscopy.

Toxocara and Gnathostoma among stray canines in Bangkok.

Stomachs and intestines of 88 adult and 112 young stray dogs were obtained from the Rabies Control Subdivision, Bangkok, and examined especially for the presence of Gnathostoma spinigerum and Toxocara canis. Forty-five dogs were found positive for T. canis (overall prevalence 22.5%) but none were found infected with G. spinigerum. The prevalence of T. canis in young dogs was 37.5% (42 of 112) whereas in adult dogs was only 3.4% (3 of 88). The total number of T. canis recovered from the 45 positive dogs was 272 (averaging 6.0 worms/dog). This includes 268 worms from 42 young dogs (averaging 6.4 worms/dog) and four worms from three adult dogs (averaging 1.3 worms/dog). The average number of worms, according to sex and stage, per young dog were as follows: male worms 2.4 +/- 3.5 (range 0-15), female worms 2.8 +/- 3.5 (0-16), immature worms 1.2 +/- 2.5 (0-9), and all worms 6.4 +/- 8.2 (1-34). The maximum number of worms per young dog was 34 while the minimum was one, and 35.7% (15/42) of these young dogs harbored only one worm. The body length of the recovered T. canis were as follows: males measuring 3.0-12.0 cm (averaging 7.1 +/- 2.1 cm), females 4.1-18.2 cm (11.0 +/- 4.1 cm), and immature worms 0.7-3.7 cm (2.1 +/- 0.8 cm).

Echinocephalus scoliodonti n.sp (nematoda: Gnathostomidae) from an elasmobranch fish, scoliodon sorrakowah (Cuvier)

Echinocephalus scoliodonti n.sp de la valva espiral del pez elasmobranquio, scoliodon sorrakowah (Cuvier) recolectado en Bheemunipatnam (Bahía de Bengala) es descrito. Un examen detallado nos ha permitido constituir una nueva especie de Echinocephalus para incorporar al gusano. Muestra notables diferencias con otras especies conocidas de Echinocephalus en relación a medidas del cuerpo, número y disposición de las papilas caudales, número de filas de espinas cafálicas, ausencia de gubernaculum y presencia de valvas esófago-intestinales. La nueva especie es nominada como Echinocephalus scoliodonti

A survey of epidemiology of Gnathostoma hispidum and experimental studies of its larvae in animals.

The present study is concerned with a survey of the epidemiology and infectivity of Gnathostoma hispidum larvae in animals. A total or 3,478 pigs were examined in Hongze-Lake, Jiangsu; Po-Lake, Anhui; and Jiujiang, in Jiangxi Province. The infection rate of G. hispidum in pigs was 14.9%. The prevalence in pigs in the lake districts (26.4%) was considerably higher than in the mountainous districts (5.1%). The results of field surveys and experimental studies revealed that in China, 38 animal species served as the first and the second intermediate hosts and paratenic hosts of G. hispidum. Among them, 23 species (6 cyclops, 13 fish, 2 frogs and one each of snake and bird) were similar to the hosts of G. spinigerum. Carnivorous fish, frogs and rodents are an important infection source for gnathostomiasis. Experiments demonstrated that Macaca mulatta was successfully infected with the early 3rd-stage larvae from cyclops or the advanced 3rd-stage larvae from fish. The domestic cat and white rat were experimentally infected by skin penetration by advanced 3rd-stage larvae of G. hispidum obtained from fish; the results of the test were all positive. The survey of epidemiology and biology of G. hispidum and G. spinigerum were quite similar, so the authors consider that humans may be infected by G. hispidum.

ELISA for immunodiagnosis of human gnathostomiasis.

An ELISA for immunodiagnosis of human gnathostomiasis using a crude water extract of third-stage larvae of G. spinigerum as antigen, and alkaline phosphatase labelled goat antihuman IgG in the indicator system was developed and evaluated. At the titre of 1:400 and above positive results were observed in 100% of 4 parasitological confirmed and 10 eosinophilic meningo-encephalitis (EME) typical of gnathostomiasis cases, 56% of 160 cutaneous migratory swelling cases, 33% of 24 cases with EME typical of A. cantonensis infections, 23% of 92 cases with other parasitic infections and 1.5% of blood donors. The overall sensitivity was 59% and specificity 84%. The predictive value was 77%. The results indicated that ELISA is potentially useful for immunodiagnosis of gnathostomiasis but improvement of sensitivity and specificity is needed.